2017 Mercyhealth Community Needs Assessment

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* 1. What is your Zip Code for your place of residence?

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* 2. Age:

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* 3. What is your gender?

Male

Female

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* 4. Which race/ethnicity best describes you?

White/Caucasian

Black/African American

American Indian/Alaska Native

Asian

Two or more races

If not listed, please self-identify

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* 5. Marital Status

Single, never married

Married

Widowed

Divorced

Separated

Living with Partner

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* 6. What is the highest level of education you have completed?

Less than high school

High school/GED

Some college, no degree

Associate degree

Bachelor’s degree

Graduate or professional degree

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* 7. What is your current employment status?

Employed Full-Time

Employed Part-Time

Self-Employed

Unemployed

Military

Homemaker

Retired

Student

Unable to work due to disability, illness, injury

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* 8. What is your annual household income (all sources included)?

Below $19,999

$20,000 to $34,999

$35,000 to $49,999

$50,000 to $75,999

$76,000 to $99,999

Over $100,000

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* 9. How many people live in your household?

Over 6

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* 10. How many people in your household under the age of 18?

No one in my household is under the age of 18

Over 6

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* 11. What language do you speak at home?

English

Spanish

Spanish and English

Other (please specify)

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* 12. What type of health insurance do you currently have?

I do not have any health insurance

Medicare

Medicare with supplement

Medicaid

Private / Commercial Insurance

HMO or PPO